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Doctors and Patients, Not Talking About Weight

Ian Hooton/Getty ImagesWhy is it so hard for doctors to talk to their patients about weight?

Doctors recognize obesity as a health problem. So why is it so hard for them to talk to their patients about it?

A new report released on Tuesday by the STOP Obesity Alliance, a collaboration of consumer, provider, government, labor and business groups, suggests both doctors and patients are frustrated with the conversations they’re having about weight.

The results of two surveys, one of primary care physicians and the other of patients, found that while most doctors want to help patients lose weight and think it is their responsibility to do so, they often don’t know what to say. The vast majority of doctors have little or no training in weight management and nutrition and, they say, they’re not likely to have anyone else in their practice who can be of help.

So while doctors may tell patients they are overweight, the conversation often ends there, said Christine C. Ferguson, director of the alliance. “It’s like going to the doctor and being told, ‘Oh, your blood sugar is high,’ and that’s the end of the conversation,” without being told about options for diabetes, she said. “Doctors don’t feel they have good information to give. They felt they didn’t have adequate tools to address this problem.”

The lack of dialogue hurts patients, too. The patient survey, of over 1,000 adults, found that most obese patients — a definition that would apply to someone who is 5-foot-6, for example, and weighed 190 pounds or more — aren’t even getting the message that they’re obese. Only 39 percent of obese people surveyed had ever been told by a health care provider that they were obese.

Of those who were told they were obese, 90 percent were also told by their doctors to lose weight, the survey found. But it’s not like they weren’t already trying: Most have tried to lose weight and may have been successful in the past — and many are still trying, the survey found. And many understand that losing even a small amount of weight can have a positive impact on their health and reduce their risk of obesity-related diseases like hypertension and diabetes.

Dr. William Bestermann Jr., medical director of Holston Medical Group, in Kingsport, Tenn., which ranks 10th in obesity among metropolitan areas in the United States, said the dialogue had to be an ongoing one and could not be dropped after just one mention of the problem. “If you’re going to be successful with helping your patients lose weight, you’re going to have to talk to them at virtually every visit about their progress, and find something to encourage them about, find progress in some aspect of their care and coach them,” he said.

He acknowledged that many doctors tend to be very pessimistic about the prospects of helping their patients lose weight. “I’ve had colleagues tell me, ‘You can’t get people to lose weight.’ ”

He has helped many of his patients lose weight, he said, by talking to them about what to eat, not just how much to eat. It’s also important to understand the role that many medications, especially diabetes medications, play in weight gain, he said.

“Part of this is that there’s this common belief, and doctors are burdened by it, too, that heavy people are weak-willed and just don’t have any willpower and are self-indulgent and all that business,” he said. “If you’re thinking it’s their problem, that they’re just self-indulgent and weak-willed and they’re not going to lose weight anyway, you’re not going to spend time having a productive conversation.”

Doctors have no solution so they don’t feel like wasting their breath. It makes them feel helpless and inadequate.
Whether or not willpower is involved, very few people successfully lose weight, and those that do certainly don’t use doctors to do so.

It seems like it would be more efficient to have a nutritionist who works with the doctors who could counsel obese patients. Like, “Stop by Maureen’s office on the way out and she can help you develop a plan that works for you.” It’s a really complex subject, and someone who specializes would provide better care than a doctor who is trying to keep up to date in so many areas already.

Also – willpower is very often not going to be sufficient for long term weight loss for many people. That’s why there are 12-step programs geared at compulsive overeaters and such.

I think you really have to know your patients and individualize recommendations. One person may be too sedentary. Another person may eat junk food three to four times a day. I always bring the topic up in the context of improving quality of life and managing medical diagnoses. You also have to be aware of your patient’s knowledge level. You may have to explain the basics to one person, yet have a detailed discussion about the latest studies with another.

People lose weight as a side effect of healthier lifestyles — diet and exercise. Doctors are great at treating disease, but as far as getting patients improved health in their daily lives it is a big challenge. Doctors don’t have the proper time to share recipes or show how to use dumbbells or assume a yoga position. Doctors can speak with authority about the benefits of losing weight and improved fitness, but a one-time doctor’s warning has the same effect on those overweight as “the talk” with smokers. Not much, but can be a starting place. Doctors can certainly be sensitive if there are medical reasons for weight gain like thyroid issues. It’s usually not an issue of medical expertise as much as habit and happenstance.

Doctors can refer obese patients to Overeaters Anonymous, which has dramatic success in helping compulsive overeaters and others with compulsive behaviors such as anorexia and bulimia. For information http://www.oa.org. It worked for me when nothing else worked. I lost 60 pounds and have kept it off for four years. One of my friends has lost 200 pounds eating healthy food purchased at the supermarket.

As someone who has struggled with excess weight my entire life, at times living with 100 extra pounds, I *never* had a doctor tell me to lose weight. In fact, one doctor suggested I just accept it as part of my heredity. My heart rate, cholesterol, etc were good, I was “just” obese. So I decided to be a “happy fat person” except that didn’t work, because I wasn’t a “happy” person. I was a person who was eating food I didn’t want, didn’t need, knew was bad for me. Why? Because I am an addict. I am addicted to excess food. Like other addicts, I turn to food as a source of coping and comfort. I knew what I was doing was not healthy or sane, but I was powerless to stop on my own. So I turned to a higher power – a 12 Step program for people with eating disorders. This truly has been a life-saving, life-changing experience. One day at a time, I experience physical, emotional, and spiritual recovery. I have a daily reprieve from the pain of eating excess food and food that will harm me. So, even if a doctor *had* told me to lose weight, until I was ready to accept my powerlessness and turn to a higher power and try something different, I could NOT have lost weight. Just one person’s story…

This is so true. Many doctors no longer even mention weight loss, whether it is as stated above, that they think their patients can’t do it, or they don’t have the language to discuss the problem. However, patients want their practitioner to give them concrete ways to lose weight, such as a referral to a weight loss center for counseling and materials. Many times, the obesity of patients is the primary problem which results in creating other afflictions. If this is not discussed by the practitioner, none of the problems will be solved in a holistic manner and the patient is left in limbo struggling to figure out which direction to take.

I’m an Emergency Doctor. In the few moments I have with patients, I would like to bring up weight as one of their health issues.
What is the best way to do this?
Is there a good form or info sheet about weight reduction/nutrition/exercise out there for me to use?

its hard to beleive that our first lady is so involved in a weight loss campain, and yet our Doctors do not know how to guide us to lose weight, or at least have an honest discussion about the problem. Do they lack training, or is it a lack of passion for helping us get better? Is this some sort of conspiracy where Doctors are leaving their patients high and dry, only to find their way to profitable enterprises like Jenny Craig and weight watchers? THere should be a reform in the medical field so that doctors can give sound advice about how to reach weight loss goals. If we hold ourselves accountable and work with a qualified doctors, then we will make steps toward getting away from being such an overweight country.

I guess I was very lucky with my primary care physician. She had a very candid, yet sensitive conversation with me about my weight at a checkup last year, and she referred me to a nutritionist, who has helped me as I’ve lost fifty pounds since. Weight shouldn’t be something doctors shy away from addressing, but it must be done with some sensitivity, too, which is perhaps what discourages them.

I think a doctor could ask a very overweight: “How many calories do you eat each day on the average” and when the person says they don’t know, lend them a digital food scale for three days. Then they could think about options.

Primary care doctors, oddly enough, know very little about preventive medicine. When I have asked questions about losing weight or taking vitamins/supplements, I get vague answers at best, or more likely, none at all.

And then doctors wonder why we go to the Internet for our medical information!!

I feel like there is a bit of a disconnect between doctors and nutrition. Sometimes I feel like I know more than my doctor in terms of nutrition… I also feel that a lot of doctors only know how to prescribe conventional medicines to deal with issues. Nutrition plays a large role in so many areas of health and to have doctors, the main people that many look to for advice about health, be ill-equipped in their knowledge of nutrition is a problem. Doctors need to be educated more thoroughly if we’re ever going to help people tackle obesity.

Obese patients don’t need doctors to tell them they’re obese. Everyone in our weight-conscious society knows if they’re overweight. I’ve never ever had an obese patient with whom I brought up the subject of their weight tell me they weren’t already concerned about it.

Yes, doctors are pessimistic about helping people lose weight because losing weight is not just a matter of biology working against obese people (which it does)–it’s also about getting people to change their behavior in a way that consistently emphasizes long-term gain over short-term pain, and that’s difficult for everyone.

I agree with Dr. Bestermann above that a physician who is consistently and persistently interested in helping his patients lose weight has a real chance to do just that. If a doctor can’t maintain a persistent approach in trying to help his patients lose weight how can he expect patients to maintain a consistent approach to actually losing it? It’s the same kind of persistence and interest that helps patient’s quit smoking and successfully manage their diabetes and hypertension. Small, consistent actions that must be maintained over time to produce a desired result are much harder to accomplish than a large action that you only have to take once.

This article was about weight loss, but the link below addresses similar underlying issues:

As a gynecologist, I often bring weight up as an issue for fertility and menstrual cycle irregularities. I am either told by patients that, since my weight is normal for my height, I have no idea what they go through to lose weight or they badger me to tell them how I keep my weight normal. When I eventually tell them (I’m a vegetarian, eat no fast food, little processed food and exercise daily), they immediately tune me out and state they have always been large. While I can’t spend as much time as I like on diet issues, I do discuss normal portion size, exercise and weight loss programs such as Weight Watchers. Hopefully over time, something clicks.

It is crucial for doctors to be honest about a patient’s weight but it is something that should be discussed with a great deal of sensitivity. Doctors need to be able to counsel patients in nutrition, physical exercise AND to identify possible emotional issues that may lead to overeating and making the wrong food choices (ex. identifying eating disorders).

This Alliance is funded by sanofi aventis (its founding sponsor), Allergan, and Amylin. The media contact is somebody at the Chandler Chicco Agency, which describes itself as a”Health care public relations firm specializing in global and country-specific corporate and product positioning and communications.”

FROM RONI RABIN: They do get funding from Sanofi, etc., but the steering committee also includes the American Diabetes Association, the American Heart Association, America’s Health Insurance Plans, the C.D.C’.s Division of Nutrition, Physical Activity and Obesity, among others. Former U.S. Surgeon General Dr. Richard H. Carmona is the health and wellness chair, and Ms. Ferguson is a former state health commissioner for Massachusetts and a research professor at George Washington University’s Department of Health Policy.

Doctors often overlook obvious nutritional and metabolic problems–treatable problems–that prevent their patients from losing weight. In my case, anemia and hypothyroidism played a role in making and keeping me fat.

Doctors routinely undertreat hypothyroid patients and fail to prescribe T3 to those who might benefit. After radioactive iodine treatment for Graves’ disease, I spent a decade both swollen and obese. I was advised to diet and exercise. It didn’t work. Finally, I found a doctor who discovered that I could not convert T4 to T3. Although my TSH was within “normal” limits, the T4 I was prescribed was doing me little good. Within 2 weeks of adding T3 to the Synthroid (T4) I was taking, I had dropped 10 pounds of swelling. With the T3, dieting works, although I need to keep my food intake below 1200 calories. And, I’m not hyperthyroid–my TSH is the same or higher than it was with Synthroid alone.

As for anemia, doctors assume that slight anemia is normal for women of childbearing age. It is not. Combine hypothyroidism and anemia, and you have a recipe for chronic exhaustion. Food can become the only thing standing between your patient and falling asleep.

Sure, talk to your patients about their weight, but make sure that you’ve done everything that you can to help them, first.

I’m a psychologist specializing in behavioral medicine. My brother is a physician who treats mainly patients with HIV. He and his practice partners tell me that patient adherence to treatment is awful and they don’t know why, but they don’t talk to the patients about barriers to compliance. I gave them a short course in Motivational Interviewing – a brief stage-of-change intervention that works way better than education or outright nagging – and discussed with them things like screening for depression, hopelessness, life stress – things that make us do maladaptive things. Hey, the patients knew they weren’t taking their meds and it’s not like they didn’t care – but they couldn’t, without help, identify why they were not doing the things that would save theri lives. The docs just plain don’t have time to do all that, so they decided to partner up with a social worker “coach” to work with patients on stress, motivation, and wellness/lifestyle change issues. Guess what? adherence skyrocketed and patients are having better outcomes.
Doctors are diagnose-and-fix guys. The have better luck when they work with someone to focus on motivational issues.

Even though none of my kids are overweight, my pediatrician always asks my children their diet and exercise habits during the well-child visits. When my son was refusing to eat vegetables, his doctor made him promise to try one new vegetable a week.